Clinical Documentation Specialist II - CDI & Clinic Qlty Doc

Position Details

Lakeland Regional Health is a leading medical center located in Central Florida. With a legacy spanning over a century, we have been dedicated to serving our community with excellence in healthcare. As the only Level 2 Trauma center for Polk, Highlands, and Hardee counties, and the second busiest Emergency Department in the US, we are committed to providing high-quality care to our diverse patient population. Our facility is licensed for 910 beds and handles over 200,000 emergency room visits annually, along with 49,000 inpatient admissions, 21,000 surgical cases, 4,000 births, and 101,000 outpatient visits.

Work Hours per Biweekly Pay Period: 80.00

Shift: Flexible

Location: 210 South Florida Avenue Lakeland, FL

Pay Rate: Min $77,521.60 Mid $96,907.20

Position Summary

The Clinical Documentation Specialist II reports to the Manager of Clinical Documentation Integrity. Concurrently reviews patient records to improve documentation to reflect accurate severity of illness and intensity of service and communicates with physicians. Works collaboratively with HIM Director, HIM Coders, and Physician Advisor to ensure accurate coding, improve the quality of DRG-related documentation, improve risk of mortality, severity of illness and case mix index. Performs other duties as assigned.

Position Responsibilities

People At The Heart Of All We Do

• Fosters an inclusive and engaged environment through teamwork and collaboration.
• Ensures patients and families have the best possible experiences across the continuum of care.
• Communicates appropriately with patients, families, team members, and our community in a manner that treasures all people as uniquely created.
• Safety And Performance Improvement
• Behaves in a mindful manner focused on self, patient, visitor, and team safety.
• Demonstrates accountability and commitment to quality work.
• Participates actively in process improvement and adoption of standard work.
• Stewardship
• Demonstrates responsible use of LRH's resources including people, finances, equipment and facilities.
• Knows and adheres to organizational and department policies and procedures.
• Standard Work: Clinical Documentation Specialist II
• Actively participates in team development, achieving dashboards, and in accomplishing department goals and objectives.
• Works collaboratively with the healthcare team to facilitate documentation within the medical record that supports patient’s severity of illness and risk of mortality.
• Reviews clinical issues with coding team as needed to ensure appropriate MSDRG/APR-DRG.
• Conducts initial and extended-stay concurrent reviews on all selected admissions for opportunities to clarify documentation in the medical record for accurate reflection of severity of illness, and documents findings.
• Ensures the proper reflection of each patient’s severity of illness, intensity of service, and risk of mortality.
• Serves as a resource for physicians and educates physicians on ways to improve their documentation so it more accurately reflects intensity of services/severity of illness.
• Identifies need to clarify documentation in records. Conducts follow-up on unanswered queries during the patient stay, as needed, to obtain a response to open queries.
• Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes including Present On Admission (POA), Patient Safety Indicators (PSI), and Hospital-Acquired Conditions (HAC). Educates internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.
• Assists in developing clinical documentation training for medical staff, UR/clinical resource coordinators, nursing and coders to ensure compliance with OIG, CMS, and other applicable regulations.
• Interacts with Physician Advisor, HIM Director, HIM Coding staff, Compliance Officer, Quality Improvement Coordinators, Department Managers, Information System staff, and Patient Financial staff on a regular basis to identify and assist in resolving documentation issues.
  

Competencies & Skills

Essential:

• Advanced clinical expertise and extensive knowledge of complex disease processes with broad clinical experience in an inpatient setting.
• Strong understanding of coding application, rules, and guidelines. Ability to formulate clinically, compliant and credible physician queries.
• In-depth knowledge of MS-DRG and APR-DRGs, documentation opportunities, coding guidelines and changes to include Coding Clinic, and clinical documentation requirements. Knowledge should also include risk adjustment, HACs and PSIs, O/E mortality and LOS.
• Requires critical thinking skills, organizational skills, written and verbal communication skills, decisive judgment, and the ability to work with minimal supervision.
• Proficient in computer use, especially with computerized encoder products and computer-assisted coding applications, EHRs, and internet research.
  
  

Essential:

Qualifications & Experience

• Bachelor Degree
  
  

Nonessential:

• Master Degree
  
  

Essential:

• Nursing degree (BS or BSN) or Bachelors in HIM or other healthcare related field
  
  

Nonessential:

• Healthcare related field
  
  

Other Information:

Experience Essential:

• 2-5 years’ acute care clinical documentation integrity experience within the past seven years. Varied experience in ED, critical care, or general medical/surgical required.
• Experience with ICD-10-CM, ICD-10- PCS, POA, HAC, and PSI coding and documentation review and DRG analysis; OR experience with clinical documentation reviews of clinical indicators and knowledge of specificity requirements.
• Experience interacting with and educating medical staff and clinical support staff.
• Prior advanced clinical expertise and extensive knowledge of complex disease processes with broad clinical experience in an inpatient setting.
• Experience in MS-DRG and APR-DRGs, risk adjustment, HACs and PSIs, O/E mortality, and LOS.
  
  

Experience Preferred:

• Prior experience with 3M 360 Encompass clinical application and Cerner PowerChart.
• Prior experience with 3M 360 Encompass worklist prioritization and Engage One
  
  

Certification Essential:

• CDIP or CCDS. If no nursing degree, must have CCS with RHIA
  
  

License Essential:

• RN (if not an RN, must have CCS with RHIT or RHIA